CDC Immigration Requirements: Technical Instructions for Gonorrhea for Panel Physicians

Preface

The medical screening for gonorrhea among persons overseas applying for US immigrant or refugee status, as well as certain non-immigrants who are required to have an overseas medical examination, hereafter referred to as applicants, is an essential component of the immigration process. Because gonorrhea must be appropriately diagnosed and treated, these Technical Instructions provide a method for recording findings from the immigration medical examination and instruct panel physicians in classifying applicants.

The instructions in this document supersede all previous Technical Instructions, Updates to the Technical Instructions, memoranda and letters to panel physicians, and memoranda and letters to international refugee resettlement organizations. These Technical Instructions are to be followed for gonorrhea screening and treatment among all applicants and are effective as of September 3, 2021.

Visit the Technical Instructions for Panel Physicians webpage for more information about the medical examination for applicants for US immigration.

Key Concepts

Gonorrhea Screening

Gonorrhea is a sexually transmitted disease caused by Neisseria gonorrhoeae. It is one of the most commonly reported communicable diseases in the United States. If symptomatic, persons with gonorrhea will most often present with urethral or cervical discharge and painful urination. However, gonorrhea is more frequently asymptomatic in both men and women, especially if the infection is in the pharynx, cervix, or rectum. Left undetected and untreated in women, gonorrhea may ultimately cause complications such as pelvic inflammatory disease (PID), tubal scarring, ectopic pregnancy, and infertility.

It is important that gonorrhea be correctly diagnosed among applicants applying for US immigration. Correct diagnosis of gonorrhea will ensure that affected applicants receive appropriate treatment, long-term sequelae are minimized, and further spread of the disease is reduced.

Medical History

Obtaining the medical history must include inquiring about any genitourinary symptoms. Men with gonorrhea may report dysuria with penile discharge, while women who are symptomatic may experience vaginal mucopurulent discharge, pelvic pain, or dyspareunia.

Physical Examination

The physical examination must include a search for signs consistent with gonorrhea in applicants 18–24 years of age (and applicants aged <18 years or >24 years if there is a reason to suspect infection with gonorrhea). Other manifestations of gonorrhea that should be evaluated include pharyngeal discharge, rash, ocular symptoms, and abdominal tenderness. However, a genital examination must not be performed for the gonorrhea portion of the medical exam. If you have reason to suspect a genital infection, proceed with laboratory testing.

Laboratory Testing

A nucleic acid amplification test (NAAT) must be performed for screening and panel physicians must use the least-invasive specimen type. For asymptomatic applicants without risk factors, a urine specimen (men or women) or a self-collected vaginal swab (women) must be used for the NAAT. Clinical judgement may be used to determine if another specimen type is more appropriate based on reported risk factors or symptoms, including oral or rectal swabs (men or women). Panel physicians must use tests that have regulatory approval in their country, and closely follow the instructions on the product inserts to ensure the correct specimen is used for the laboratory test, as collection methods and specimen types vary.

While gram stains on urethral secretions may be diagnostic in symptomatic men, they cannot be used to rule out infection in asymptomatic men or on other types of specimens. Therefore, gram stains are not accepted for gonorrhea screening in the immigration medical exam.

Many gonorrhea tests automatically test for Chlamydia trachomatis. Although chlamydia is not listed in the diseases of public health significance in 42 Code of Federal Regulations (CFR) part 34, panel physicians may use tests kits that screen for both gonorrhea and chlamydia if gonorrhea stand-alone test kits are unavailable; when combined test kits are used, applicants must be informed of results for both gonorrhea and chlamydia. Applicants who test positive for chlamydia only must be offered treatment in accordance with the CDC’s Sexually Transmitted Infections (STI) Treatment Guidelines; however, the applicant is not required to take this treatment as chlamydia is not a Class A condition. If an applicant is tested for chlamydia, the results must be documented in the DS-3026 remarks section (but not under Section 8 where gonorrhea diagnosis and treatment are documented) or in the other medical conditions box in the 501 Medical Exam in the eMedical USA system.  If an applicant is diagnosed and treated for chlamydia, this must also be documented in the DS-3026 remarks section (but not under Section 8 where gonorrhea diagnosis and treatment are documented) or in the other medical conditions box in the 501 Medical Exam in the eMedical USA system.  Applicants diagnosed and successfully treated for chlamydia should receive a Class B Other classification.

All applicants diagnosed with gonorrhea should be advised to be tested for other STIs, including chlamydia, syphilis, and HIV. The consent for HIV testing should include the following:

• Applicants understand they do not have to be tested for HIV.
• Applicants understand that if they would like to be tested for HIV, they do not have to be tested for HIV by a panel physician.
• Applicants understand that panel physicians must include the test results on the paperwork they complete.

If the applicant consents, panel physicians should perform HIV testing consistent with the standards of care, including pre-test and post-test counseling for the HIV test.

Gonorrhea Screening Results and Travel Clearance

Gonorrhea Treatment

Panel physicians must treat gonorrhea according to CDC’s STI Treatment Guidelines, which are periodically updated, before the medical report form is completed and signed.

Treatment must be provided onsite and be directly observed. Panel physicians should recommend that sex partners of infected applicants also be treated. Additionally, if an applicant is diagnosed with a gonorrheal infection using a stand-alone gonorrhea test kit and chlamydial infection has not been excluded, panel physicians should offer treatment for chlamydia in accordance with the CDC’s STI Treatment Guidelines; however, the applicant is not required to take this treatment as chlamydia is not a Class A condition.

Evaluation Post-treatment

A test of cure immediately at the conclusion of therapy is not needed prior to completion of the medical examination following treatment for uncomplicated urogenital or rectal gonorrhea that is treated with any of the recommended or alternative regimens. However, any applicant diagnosed with pharyngeal gonorrhea must have a NAAT or culture test performed 14 days after treatment prior to completion of the medical examination, and the test must be performed by the panel physician. If the NAAT is used and is positive, the applicant must have confirmatory culture with drug-susceptibility testing before re-treatment.

Treatment failure should be considered in 1) persons whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period. and 2) persons with a positive test-of-cure (i.e., positive cultures ≥72 hours or positive NAAT ≥7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period. In cases of suspected or documented treatment failure, panel physicians must perform both culture and drug-susceptibility testing because non-culture tests cannot provide drug-susceptibility results.  Culture requires endocervical swabs (women), urethral swabs (men), or oral or rectal swabs (men or women). Additionally, gonococcal cultures require demanding nutritional and environmental growth requirements. Optimal recovery rates are achieved when specimens are inoculated directly and when the growth medium is incubated with an increased CO₂ environment.

Because a high prevalence of N. gonorrhea infection has been detected among persons previously treated for gonorrhea, all applicants treated for gonorrhea should be counseled that they should be retested 3 months after treatment. However, this post-treatment evaluation does not prevent travel to the United States.

Waivers

A provision allows applicants with a Class A physical disorder to petition for a Class A waiver. The Application for Waiver of Grounds of Inadmissibility Form (I-601 or I-602 for immigrants or refugees, respectively) must be completed. These waivers are submitted to the Department of Homeland Security (DHS), US Citizenship and Immigration Services (USCIS) on an individual basis. The Division of Global Migration Health (DGMH) also reviews the waivers and supporting medical examination to provide an opinion regarding the case to the requesting entity (Department of State or DHS, USCIS). DGMH’s review of the waiver and supporting medical examination documentation is to ensure that the applicant has been classified properly and that an appropriate US healthcare provider is identified for the applicant. DHS, USCIS has the final authority to adjudicate the waiver request.

Documentation

Department of State (DOS) forms Medical Examination for Immigrant or Refugee Applicant (DS-2054), Vaccination Documentation Worksheet (DS-3025), Medical History and Physical Examination Worksheet (DS-3026), and Tuberculosis Worksheet (DS-3030) must be completed in their entirety and included in the applicant’s travel packet, or within the eMedical USA system, specifically the 713 Gonorrhea Test exam. This includes assigning a classification for gonorrhea (Class A or Class B) on the DS-2054 or the appropriate section in the eMedical USA system and attaching laboratory reports. Incomplete documentation may result in refusal to grant a visa or designation of medical hold status at arrival to US ports of entry.

For applicants requiring gonorrhea treatment prior to US immigration, the panel physician is required to document the following on the DS-3026 or in the 713 Gonorrhea Test exam in the eMedical USA system:

• Laboratory test used to make the diagnosis and date of test.
• Drug regimen received (including doses, dosage units, and administration routes of all medications), start date, completion date, and any periods of interruption.
• Clinical course observed, if applicable, such as clinical improvement or lack of improvement during and after treatment, including resolution of symptoms and signs, as well as any drug reactions.

Glossary of Abbreviations